RE-RUN - Ozempic Weight Loss Debate with Obesity Specialist Dr. Rocio Salas-Whalen – Side Effects, Risks & Benefits

28:45More than ever, I've never recommended to my patients to go to the gym or personal trainers as much as I'm doing every day now. Yeah.

28:54Dr. Rocio Salas-Whalen:Well, I do have to say it's, you know, I have women coming into my courses all the time, either one-on-one or in these groups that I run multiple times a year. And when I'm running the numbers, like I always, like there's always a couple of obese people that come into the group. And emotionally, I am like, I don't want this to be another source of failure for them. because so this totally I mean, from my point of view, when I've been on these, you know, panels, I'm like this, this only helps us because it's giving someone that they're then they're like, okay, well, I don't have as much noise in my head.

29:38Dr. Rocio Salas-Whalen:I'm seeing some change. So now I can take on this education component or, you know, and the behavior change and habit change and all of those things that are needed when someone starts to wean off of the drug. Do you recommend, I mean, I know this is still fairly new and this may change. Do you have like, can somebody be on this for the rest of their life or is the goal to get them to a place where you're like, okay, we're going to wean you off, but the habits, the behaviors, the education has to be there as well. So if we go back to what obesity is, that it's a chronic disease and chronic diseases, we don't cure, right?

30:20We control. So the idea with these medications is that they're designed for long term use. And one, I think it's a I think we should shift it as a positive thing and not as a negative thing. Because for the first time, we we have something that's going to help you maintain the weight loss, right? Because many things can probably take you there restrictive diets. but the moment that you stop or that you're left on your own is when the weight regain happens so with this medications we can not only take you to your goal but we can help you keep you on your goal they're safe to be used long term if we're talking about safety now weight loss medicine is very new and a lot of things are changing and we're learning as we're doing and if i can talk about my personal experience with my patients, those patients are able to maintain their muscle mass.

31:13Those patients are able to gain muscle mass. I have more a probability to maintaining the weight loss at the lowest dose possible or with maybe no medication. Right. Because whenever you You hear, oh, losing weight slows down your metabolism. The reason for that is because you lose muscle with weight loss, right? With any, and this is not exclusive to semaglutide. This is not exclusive to any of the drugs that we're talking. This is just exclusive of dieting. Patients lose muscle. Muscle is our most, and you know this, muscle is our most metabolic organ, right? It's our burning machine. It's our burning calorie machine.

31:54So if you lose it while you're losing weight, that's what's slowing down your metabolism. But if when you're losing the body fat, you're maintaining your muscle or even gaining muscle, that becomes part of the maintenance for the weight loss.

32:10Dr. Rocio Salas-Whalen:yes and i think it's interesting too that a lot of you know young trainers or just people not even in the profession think that they're it's shocking to think that like someone who is obese they carry a lot of muscle mass they also carry a lot of fat mass but it's assumed that they just don't have a lot of muscle mass and that's not the case. Well, it's interesting because research has shown that yes, people with obesity have more muscle mass, but it's not healthy, all healthy muscle mass because there is fat in between the muscle fibers. So it's not necessarily that their, that their metabolism is higher because they have so much muscle.

32:56Their muscle is not the same when is lean muscle. Okay. That's the ticket right there. So when you're on this medication, it really is way more beneficial to strength train and work out while you take this medication. 100%. So, and it's strength training, what I recommend, right? Persistence training, strength training. It's important for many patients. It will take time. It will take 20, 30 pounds of weight loss before they feel motivated physically and mentally motivated to go to exercise right but i always have that the initial consult is always half of it is going to be exercise and protein exercise and protein or exercise and diet doesn't replace the medications Yep.

33:50The medications don't replace exercise and dieting. It's hand in hand. Yeah. All of the components. Okay. So what about people that are taking it that aren't obese, but they just have that like 10 to 15 pounds and they just want to do it short term and take it like patients that come to you. I mean, do you have any patients like that? Yes. And it's easy to say when somebody, oh, it's only 10, only 15, only 20 pounds that I may have to lose. And whenever I do a body composition, it turns out that they have really high visceral fat or they have more than 10 pounds to lose. Right. Right. So if we go by the number and the scale or we go by the BMI, I think we are under treating many patients that can be that should be treated.

34:48Right. So I feel like it's not fair to say this patient doesn't need it just by looking at them without knowing their body composition. Right. And then for those patients that are are doing what they should and they still cannot lose those 20 pounds. then I dig more deeper into how much is this consuming your life right how much is this take over your day and for some patients it becomes again a 24 7 to lose 20 30 pounds or 10 15 pounds then those patients if they didn't do what they were doing probably they will need more pounds to lose so those patients would benefit from the medication right absolutely they're they're being consumed by that and and and if we put their perimenopause menopause then it's going to be classic that they're doing what they were doing in their 30s early 40s and it's not happening and they keep gaining weight and it's because of those change of hormones right yeah which brings me to my next topic this is the next big topic that hayley and i love to talk about the hormone

35:56Dr. Rocio Salas-Whalen:replacement therapy the ozempic study that just came out which i haven't had time to read because I just launched a course a few days ago and I'm like buried, but I've seen you talk about it already and I've seen it on social media. So can we talk about that weight loss response in, in regards with, into hormone replacement therapy? So in this study, it showed that women that were on HRT on hormone replacement therapy and semilutide versus the ones that were just on HRT, they lost more than 30 % more weight loss than the ones that were not, that was not on semaglutide with HRT. It's a very small study, right?

36:39I feel like before we jump the gun into saying that HRT helps with weight loss, what it does, it changes your body composition. When we lose estrogen, when we lose estrogen, the body fat that was in our fertile years, in our hip, in our legs, goes intravisceral, so in our midline, right? When we give back the estrogen, there is, again, that change in body composition. We lose visceral fat. It goes more into our fertile years areas, but it doesn't cause weight loss. It just changes the body distribution. Now, we know that with perimenopause and menopause, especially with the hot flashes, the lack of sleep, that demotivates a woman to exercise, right?

37:22Because you're tired, you're not sleeping well, you have the hot flashes. So they didn't look that in the study. If their lifestyle changed it, that they were more prone to follow a healthy lifestyle just from the decrease of some of the perimenopausal symptoms, including depression, mental health, changing mood. So it's not the actual hormone replacement therapy causing the weight loss it's we we don't know if there were other factors involved because

37:51Dr. Rocio Salas-Whalen:they didn't check them well i just love that there's a study on this this early with menopausal women because as you know and i know and like it's it's just we always get the shaft in this age group it's like oh well you know but i i always tell my friends and patients i said this is we're living in the right time to be this age. Yeah, I could not agree more. That was one of my fears in Gov. Things are changing and I'm so happy and I'm so excited for women and for myself and for my daughters because we have, once we were accepting more hormone replacement therapy, we know it's safe. We know the short-term benefits and the long-term benefits, right?

38:42And now we have medications that can help us with weight loss that, for whatever reason, it cannot happen on its own. So we are building superwomen, superhuman. And I feel like it's well-deserved. We waited for a long time. You know, no more mental health, no more putting on antidepressants, no more getting the short stick of the end. It's just no more gaslighting of our symptoms, basically. Yes. One amen. I know. I've been terrified to go through menopause because I thought my biggest fear was I'm not going to have control of my body because that's kind of what the conversation always leads to.

39:28All of a sudden I've gained weight. I'm exhausted. The hormones, all of the things. And like now we have all these tools. We have hormone replacement, this medication, everything else. And it doesn't scare me, which feels empowering. A hundred percent. And the best anti-aging is muscle, right? So we also have this concept now. We're accepting this concept that not more exercising just to lose weight, but for longevity and anti-aging. So we're packed with our hormones, our semaglutide and our weightlifting. We have all the tools for a long, healthy, high quality of life. Yeah. Oh, I have full body chills.

40:14Dr. Rocio Salas-Whalen:I'm so. Me too. That was like perfection. That needs to be like on a billboard or something. That was it. Let's make it a t-shirt. No, it's just, you know, it's like, I feel like we women, like we get asked for so much and we have so much pressure that even like midlife is like, okay, now how are you going to uh what are you gonna do now new right like you have to reinvent yourself and yeah it's like no we've done enough i feel like also we should see it as a just a continuation of our life it doesn't have to be this big change that oh what are we gonna do now just continue being as fabulous as you were before going through yeah menopause it's just a continuation of our mental life our sex life, which I think it's very important.

41:03And I feel like many women let it go and give up after children or after 40 or after 50. It's like, we don't deserve a sex life. We, we had enough. We had our kids. No, you deserve a healthy, satisfying sexual life, physical life. So we, we, we have the tools. I appreciate you saying all of that. I, that speaks volumes to me, I feel like.

41:32Dr. Rocio Salas-Whalen:So what what are the drugs that are there any drugs coming up? I remember you saying something like this and it piqued my interest a few months ago about a new drug coming out. Maybe it's out already. I'm not sure the timeline. It was probably six months ago that there's a new drug that can help hold on to muscle mass. Like, how is that? So what is that? This, what we're seeing right now in semaglutide osempec is the tip, right? It's just, it's the beginning of very sophisticated drugs that are coming our way. One of them is one that promotes the weight loss that has the GLP part, and it has medication that will help prevent muscle loss and help muscle gain in the drug, right?

42:24What? Sign me up for that. Is there a trial? So there is, again, the drugs are going to become very sophisticated in the future. This is just the beginning. I mean, this, what we're seeing now is probably the biggest event in medicine that we're going to see in our lifetime happening. So exciting.

42:47Dr. Rocio Salas-Whalen:Oh, so what is your professional opinion then about if there is a drug that can hang on to muscle or even grow muscle, why would somebody need to eat a lot of protein and weight train? Because you need protein, you need the amino acids to build muscle, right? That is not sustainable. I mean, nutrition, I don't think there will be a point that will be replaceable by a drug. Right. We we we need food and our muscles need amino acids. Right. To build muscle. So you can have a pro you can have a protein or or a medication that prevents muscle loss. But you still need the basis to promote muscle gain and to maintain muscle.

43:37Right.

43:38Dr. Rocio Salas-Whalen:I'm trying to foresee the questions that will come up. Yeah, no, and again, this is not out yet. And even when a medication comes out, you have to realize those are control studies of 1 ,000, 2 ,000, 3 ,000. But once it's out in the public, then we learn more about them, right, and what is still needed or not needed. Like Osempec, these medications in the studies, they never did body compositions. So they didn't know that there was muscle loss. until now we're doing it and we're doing body compositions and everybody. And we're like, oh, they lost 30 pounds, but 10 were muscle. So we're fixing that.

44:20So the same way is going to be with the future drugs.

44:26Dr. Rocio Salas-Whalen:So if somebody comes into you, I think this is the other issue. How? Because it can be like five hundred, seven hundred dollars a month. Does insurance cover it for everyone or is it still hit and miss? Yeah, insurance is the rock of every doctor in the show. Yeah, I bet. How is it this crazy in America? Like, can we not fix it? When there was shortage of the medication, oh, I see all my assistants in my office, I call it the hunger games. It was like getting to see who had the pharmacy, who had the pharmacy, had it or not. And the insurance, who would approve it? Right now there's guidelines that the insurances go by And it's the guidelines that were done by the Obesity Society and the Obesity Medical Association, where they state that BMI equal or greater to 27 with one comorbidity, and this could be sleep apnea, osteoarthritis, high cholesterol, are approved for weight loss medication.

45:27Or a BMI equal or greater than 30 without any comorbidity, they meet the qualifications for weight loss medications, right? So you have a patient that may meet the qualifications, but then the insurance may not have it on their plan. So it's not just that you meet the qualifications that the insurance requires, but also that they actually have it in their plan. And some insurances have what they call exclusions, and those are never approved, even that you meet the qualifications. and because these medications are relatively expensive, so most insurances don't have them in their formulary. Now, if you're going to pay out of pocket with the medication, then we're bypassing the insurance, right?

46:12But there are expensive medications. But my question is how much money do people spend on all the other diets, right, that they've gone through, thousands through their lifetime? And how much is your health worth to you, in my opinion? I mean, if someone said, I mean, I don't know the cost of all of them, but I don't know. I would say that your health should be the number one most important thing that you're spending your money and time on. Yeah. And for out-of-pocket, both pharmaceuticals right now that have coupons, if you have a commercial insurance and you're out-of-pocket, meaning that the insurance is not covering it, they have a coupon and it comes out to about$500 a month, either Osempic, Ovi, Monjaro, or Sepon.

47:00They're more likely around the same price. If you don't have insurance, then it's about$1 ,100 a month. oh my gosh it's a lot yeah that is a lot but how scary is it to take something like

47:16Dr. Rocio Salas-Whalen:you know a lot of the americans i'm not gonna say that i've never done it go to mexico and get like a sleep drug or something like how dangerous would it be for i'm sure there's nine million places that you can get it but like you said it's not through a physician it's not managed can, I mean, I'm sure those can be dangerous. Just for you to know, it's unfortunately in the U.S. how the prices of the medications are ridiculously high. This drugs, Osempec, in a pharmacy here in the United States out of pocket is going to be$1 ,100 for a month's supply. If you go anywhere else outside, not just Mexico, if you go to the Middle East, in Europe, and in Latin America, it's about$200 a month.

48:02Dr. Rocio Salas-Whalen:Oh my God. What? Okay, so it is the same though. It is. It's not like sketchy. It's the same. This makes me so mad, like about America, because I had a son that that needed Accutane and we were on like private insurance at the time, like our own insurance. My husband owned his own business at the time and it was$500 a month. and that was a hard pill to swallow but I'm like my teen doesn't want to go outside but then when we swapped somewhere in between the 18 months or what I don't know how long he was on it but another one was five was five dollars a month just like a main provider insurance and I was like this is there should not be that discrepancy of 500 and for any medication like I don't know it it really is frustrating it is very frustrating it is very frustrating and so you have people and then we like there's a Canadian there's Canadian pharmacies that they can patients get it for about three hundred dollars a month um with a from a from a U.S.

49:15prescription well that's helpful yes it is yeah do you think there'll be a shortage again since there's it's like such a big medication there are small shortages of certain doses from time to time but i feel like the production eli lily is doing the best they're building factors as we speak to be able to to supply but it's just that demand is so great right yeah well i know i was in australia

49:51Dr. Rocio Salas-Whalen:the first of the year. And they were all sold out. Well, as the strength and conditioning coaches were saying, because all the bodybuilders were like hugging it from everyone, which is terrible. I mean, it's, you know, like, I don't know if there's a shortage now, but I know that they were like, again, there were two sides to the story, but down there it's very different, obviously, than here as well. Every country has their own kind of issues and things, but we've got to get the insurance part figured out here in America, for sure. Even for patients and for doctors, honestly. Yeah. It hurts both sides.

50:36Dr. Rocio Salas-Whalen:I mean, I ended up going, I ended up having a knee surgery, a major knee surgery at HSS in New York. And one of the top physicians that, there were like two that did this specific knee surgery on women over 40 because it's a terrible success rate. And the doctor's like, well, here's my price. I'm like, I'm out of pocket. And I was like, take my money. I mean, I was so desperate because I'd been a year with just like nothing. But I get why physicians are just like, I'm not working with us anymore. It's a circus. Insurance in my office. But this is the only way I can spend one hour with my patients.

51:18right yeah and when you're talking to someone with obesity that they've struggled through childhood and they're in an adult life you cannot have this conversation in 15 minutes you cannot open to anybody in 15 minutes you cannot earn a trust and build a relationship with a 15-minute

51:36Dr. Rocio Salas-Whalen:appointment right no i'm in love with you and i'm like you need to be in let's on a trip to New York, Kaylee. Yes, I know. We're going to New York. And I mean, I just think of all of these people that that that have reached out to me that like, I mean, they need you on speed dial. I don't even know. Are you taking new patients? Yes, I am. You do Zoom like so for people that don't live in New York. Yes, I do telemedicine. I have patients all over the world. And you're about to not be accepting new patients because everyone is going to be obsessed and like coming to you get on the wait list for a year no I'm working very hard so I can accept I cannot see everybody I accepted that and I can't yeah but I'm trying to see as much as I can I love that I do too well okay so before we close and this is something that we should have talked about at the very first but I've just been so it's been so fascinating this entire conversation.

52:40Dr. Rocio Salas-Whalen:Can you explain for people? I feel like everyone knows about these drugs now, especially from like Oprah, you know, has talked about it a lot. And obviously a lot of big people on social media. But for someone that's like, oh, OK, I know that this is a weight loss drug. But what is it actually doing to help me lose weight for people that don't understand that part? So the pharmacology of this drug is they're synthetic hormones. We make this hormone GLP-1 in our small gut. And what they do, we have receptors for this hormone all over our body. But in regards to weight loss, what they do is in our gut, in our stomach, we have receptors that when we have this medication, when we take this medication, When this hormone is there, it increases our satiety hormones, so it activates our satiety.

53:37So when you start eating, it activates your satiety signals, and you get fuller with smaller portions of food. And then in between meals, it suppresses your hunger hormones. So when you feel hungry, you eat a small portion, you get physically full and satisfied, and then you're not hungry for a few hours. Then you get hungry again, but then you eat a small normal portion, right? and then in our brain in the hedonistic eating and drinking area where we eat for our reward for pleasure anxiety boredom it takes away any anticipation of our reward from food or alcohol so if you think about it let's say a glass of wine whenever we think oh i'm gonna have a glass of wine at night you're anticipating i'm gonna feel relaxed i'm gonna feel this i'm gonna be in a social setting, it takes away that anticipation.

54:30You reach for it and it doesn't give you that back anymore and the behavior changes. Same with foods of some patients that eat order more anxiety at night or binge at night. It's because you're seeking some sort of relief or some sort of reward. It takes it away. You still enjoy your food when you're eating and you're hungry, but when you're physically content, you don't think of food anymore besides as food when you're hungry. So that's what that noise that people say that stops is because you're not, you don't, and then, and then it's not like you don't have anything else to look for because many patients said, well, food is my, my pleasure is you replace it for something else.

55:12Many patients replace it with exercising, anything else, then it's not going to be food. And for some, many alcohol, which is another great thing with these medications is that it cuts. Yes, there's so many benefits. Okay, so if one of if a patient is on this long term, do they usually have to stay at the same dose? Or do you have to increase it or decrease it? Because depending how much weight we're talking about, right? I mean, I've had patients, the one that lost the most is 170 pounds. Wow. So they work. I mean, when they work, they work great. But to get to, let's say, to that goal or to 30, 40 pounds, we may use higher doses to get there.

55:58But once we're there, when we're in maintenance, that we're not looking for any more weight loss, I cut back on the doses. And this slowly, as slowly we went up, slowly we go down because we're not looking for more weight loss. The patient can be eating a little bit more for maintenance. that makes sense i cannot believe the behavior psychological changes all the benefits that come from this drug i've had grown men cry in my office that for the first time they feel relief

56:37Dr. Rocio Salas-Whalen:yeah that's okay so wrapping up laura do you have any other questions no i i feel like you explain this so well. And I don't know, this has been such an exciting conversation. I'm much needed conversation too. So to kind of wrap up and you have mentioned this now multiple times in, in this interview, the biggest thing about the weight loss, I mean, I'm just zoning out on one portion, but the muscle mass is so imperative to keep for a myriad of reasons. But mainly if we're looking at like, we don't want the resting metabolic rate to go down from the lack, from the loss of muscle, especially these perimenopause, postmenopausal women.

57:31Dr. Rocio Salas-Whalen:So So that has to be the priority, the high protein, the strength training, you know, along with something like this for those who need it. That's like the magic. That's the trifecta. Yeah. And even that I didn't mention this, but what I see in my body compositions in my patients is that when they lose muscle mass, they could be in one, they could be in two weight loss medications. they might have lost 10 pounds if they lose muscle mass their percentage body fat may go up even though they lost weight right so muscle is so imperative for the proper benefit or the maximum benefit of the medication and when patients see this when they see that they lost muscle and they gain percentage body fat, it switches completely, right?

58:29They get why it matters so much. So I really think we should focus more on muscle gain or preserving muscle than weight loss or fat loss. Because if we concentrate on the muscle, preserving the muscle or muscle gain, the fat loss is happening. To maximize the benefits of these drugs, you need to have the conversation about muscle.

58:57Dr. Rocio Salas-Whalen:There it is. Mic drop. Mic drop. Nothing else needs to be said. Okay. Dr. Whalen, thank you so much for joining us this. I appreciate your time. I know you're on spring break with your kids taking time away. So we are so grateful. I cannot wait for this episode to air. So thank you so much for joining us. Thank you for inviting me. I really enjoy this. We should do it again. Talking about exclusively perimenopause and menopause woman. I think we should. Yes, let's do it. That's round two. We deserve a full podcast just for them. Okay, we're doing it. Thanks so much. Thanks for listening, everyone.

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